in Rochester, Minnesota. I would like to present our abstract on the Heartbeat to Home, a Successful Same Day Dismissal Strategy. This project would not have been possible without my colleague, Chris Neelan, and at the time, our Heart Rhythm Division Chair, Dr. Tom Munger. As a clinical nurse specialist, I support heart rhythm services in the cath lab in Rochester. And just a quick note on my role, because many people do not know what a CNS is. A clinical nurse specialist is an advanced practice nurse who specializes in clinical expertise. They utilize advanced knowledge and evidence to diagnose and treat patients, lead evidence-based nursing practice, and facilitate organizational change. So think back to October of 2020. Think about all the hospitalizations that were occurring at that time. We knew it was occurring on the East and West Coast that the hospitals were filling up with COVID patients. Being in the Upper Midwest, winter was setting in. Directives were given to all practices to reduce your procedural patients that needed to stay in the hospital overnight. We had to prepare for the surge of patients that would be anticipated. We knew we had to act fast and to save hospital beds for those who really needed it. And then November happened. We had to completely sidestep our plan. And on a Thursday in November, we were told, you're going live on Monday. Go. So when we were implementing a same-day dismissal process, we knew we had to tailor the plan to a specific group of patients, maintain our excellent quality outcomes without affecting our patient care, keeping our patient satisfaction high, but also it was imperative to reduce the amount of hospital beds that were being utilized. So pre-implementation, this is what our numbers look like. We had, to give you an idea, we had our, for our device cases, we were only dismissing on the same day, which is an outpatient procedure, was generator changes. On our EP cases, and that was at 23%, but on our EP cases, it was only 14%, and those were AV nodes and EP studies. Otherwise, all other cases were always hospitalized. So for an implementation strategy, there was very little literature out there. As a CNS, I go to the literature, I see what's out there. Back in 2020, not a whole lot of literature on the same-day dismissal. For on device side, we decided to look at all devices possible that were gonna be dismissed on the same-day dismissal. The only cases that we did not do a same-day dismissal was if they were device dependent or if they had a leadless pacemaker, and that was due to the size of the sheath for those micros. And we just didn't have, at that time, enough evidence within the micros to feel comfortable sending them home the same day. For our EP cases, we chose cases that were not highly arrhythmogenic at the beginning of our same-day dismissal process. We did create a process for our inpatients as well, along with our pediatric patients. In our pediatric patients, we did dismiss same day, but on our inpatients, for our device cases, we set up the program for them. However, the primary team would have to make the determination if they would be dismissed the same day. So process flows, that's my specialty as a CNS. I went to all the stakeholders and consulted them, and workflows were created to help make sure that we were having a smooth transition with this new workflow. It started within a clinic, identifying the patients up front as potential candidates for the procedural, and then all the way through to the PACU dismissal. All roles that touched the patient were included to ensure that this process was, that essential processes were not missed. So this here is just a first iteration of one of our workflows. So we have the type of appointment, the timeframe that the patient would go through, the staff that were involved, the education, sorry, the education that would be involved, and then the notes, just notes that were needed for considerations for each step of the way. So the first one was device, and then this one is on the EP side as well. So go-live considerations that we had to take up. So now we're live, and what do we have to do? We needed to make sure that our processes were not being, we were having a good process that we weren't implementing patient outcomes. So we were meeting on a weekly basis with nursing leadership, MD leadership, and then our APP leadership. Feedback about the process was gathered all throughout from our device charge nurses, our EP charge nurses, from our PACU, from our clinic, all the way through. We did this in a fluid process with PDSA cycles, with robust communication to all the teams as the processes changed frequently through our implementation. We made sure to monitor clinical patient outcomes so that they were not, if there was something that was going wrong that we were finding, that we would, again, pivot. So what did our numbers look like? After the first three months post-implementation, because we were meeting weekly, and we wanted to make sure that we were doing well with it. During that time, we actually did not find that any, well, one, there was one EP case that had to come back to the ED, and there was one EP case that then had to be re-hospitalized. We were actually able to increase our save-day dismissals on the device cases up to 35%, and our EP cases up to 31%. But remember, we're trying to save beds, so how does this translate to beds? For our device cases, it was a 51% increase with 102 beds saved within that first three months, and our EP cases, it was increased by 121% with 82 beds saved in three months. So, that's 184 patients in three months. But what about this long-term? So, this is a look after 40 months of implementation when we did this. So this is the beginning of 2024 that we had this. For our device cases, we had a 65% increase in same-day dismissal over that 40 months, which is 2,295 beds saved. And then for our EP cases, we had a 250% increase in same-day dismissals with 1,924 beds saved. So, as you can see on the results here, on the left-hand side is the device cases. You can see that, still that slower uptick, trend line for that 65%, and then our EP cases were that 250% increase occurred. So, what does this mean for continued progress? What does our practice look now that it's been four and a half years that we've implemented this? We continue to adapt to a changing environment of the device and EP world. PFA cases are shorter. Which means higher volumes of same-day dismissals for the practice. We continue to evaluate the bed rest times, pushing the time shorter to help with tight space within our PACU. Using new devices, new technology, to also reduce the bed rest time. Finding that quality of care and the clinical outcomes were being maintained. We still meet, we have a quality specialist that looks at every single case that comes through our lab, and they look at, they adjudicate every single case to see if there's any quality outcomes that needed to be reported. So, what was once a novel idea for the practice is met with some resistance. It is now the standard of care for our practice in Mayo Clinic in Rochester. Here is our references, and when I say there is very little literature, this is what was out there. So, we have time for questions. Hi everyone, my name is Kaitlyn Quach. I'm a third-year medical student at the Oakland University William Beaumont School of Medicine. Today I'll be presenting on my capstone project which is on the impact of personalized visual medication charts on patients with arrhythmias. So I want to start off talking about polypharmacy which is commonly referred to as the use of five or more medications at the same time. This is a very common problem seen in patients with cardiovascular disease. There's a wide range of incidents that has been reported from 30% in adults with congenital heart disease to 88% in patients with coronary artery disease. So there's a lot of different consequences of polypharmacy including increased risk of mortality and increased risk of drug interaction. There's one study that found almost 80% of patients with cardiovascular disease had at least one severe potential drug interaction. The most common being risk of QT prolongation and increased risk of CNS depression. So there's a lot of different factors associated with medication non-adherence and many studies have suggested that polypharmacy is definitely a big risk factor in this. And part of this might be due to a patient's lower understanding of medications as their pill burden increases. So when we talk about medication knowledge we kind of have to address this gap that exists between the health care provider and the patient. Health care providers often refer to medications by name and dosage while patients remember their medications by color and shape. There's a study that surveyed patients on how they administer their medications and 72% of them said they rely on the pill appearance to make sure they're taking the right medication. So we propose the use of a visual medication chart to bridge this knowledge gap. And the point of the visual medication chart is to display all the pertinent information of a patient's medications and include a picture of the corresponding pill. We think that if patients can quickly look at a chart and better associate the pill appearance with the name and dosage they may have an easier time remembering this information. So our study wants to see if this use of a visual medication chart will increase medication knowledge particularly in patients with arrhythmias over a three to six month period. So we set up this study as a prospective cohort study using a convenient sample of patients at our ambulatory cardiology clinics. Patients that were scheduled for an appointment they were screened for eligibility and then the eligible patients if they agreed to participate and once they were consented they're placed in the intervention or control group. For this study in particular we did the intervention group first and then we did the control group second. So at the first visit we obtained a baseline medication knowledge which I'll talk more about in the next slide and then for the intervention group they were printed out a copy of their personalized visual medication chart. Then three to six months later we called all the patients for a follow-up and we reassessed their medication knowledge and also documented any medication changes that might have occurred during this time. So to assess medication knowledge we used a four-point scale and of note we only use cardiac medications for this study as we wanted to see if patients could recall the name, dose, frequency, and indication of all their cardiac medications. So they were given one point if they got the correct answer and they were given zero points if they gave an incorrect answer or they couldn't recall the answer. And then based on the total score we characterize their medication knowledge as a percent of correct answers. So the way I made the pill chart for the intervention group is on Google Sheets. I created like a dictionary of all the common medications and I coded it in a way that if I typed it in this blank area here all the information would automatically fill out. And so then I'll kind of show a video example of how I did. We're taking Eliquis for example here. I would go these are the information that I wanted highlighted in the chart and I would define it as Eliquis 5 so that way when I typed it in the area Eliquis 5 all this information would autofill so I wouldn't have to do that for every medication. So it's showing an example there of how I typed that in and then it'll come to autofill and then for each of the patients I would just fill in their subsequent medications. So I wouldn't have to fill out this information and it makes making the chart a lot faster. So in the end the chart would look something like this and then for Eliquis it's a little easier because it hasn't gone generic yet but for things like rosuvastatin I would pull up a site called Apocrates and that has a pictures of all the pills different versions that a patient can take and usually the patient will just point to the pill that looks most similar to what they're taking or if they had brought in their pills for that visit then I would pull in the associated picture. And so when it's printed I put a comparison of what my wallet size and it's something that's supposed to be easy to carry around for them or even to put next to their pill box so they can easily look at it right away. So these are the number of patients that completed follow-up I think we had a pretty good follow-up rate and then just as a reminder for this presentation we're just doing a sub analysis on the patients with arrhythmias. So these are the baseline characteristics of our patients there were no significant differences between the two groups. I did want to point out that the median number of medications or cardiac medications was five for both groups so with cardiac medications alone in our population they're already meeting that criteria for polypharmacy. And then another note for the health literacy score this was reverse scoring so the lower the number the higher the health literacy. And then these are the common comorbidities in our patients the only significant difference was hypertension there was more in the intervention group than the control group. So these are the changes that we documented at the follow-up phone call across both cohorts 45% of patients had a medication change whether that was an addition or removal and then 16% of patients had a doses chain. So just within this short time period there's already a significant amount of medication changes that are occurring in these patients. So as for the medication knowledge itself we'll go start with the control group. The median medication knowledge score was 81% at baseline and then at follow-up it was 83% so the paired t-test showed no significant difference between the two group scores. And then for the intervention group the baseline medication knowledge score was 78% and the follow-up score was 85% so paired t-test did show a significant difference between these two scores. So to put this all together I wanted to include my research mentor Dr. Mehta to kind of do the discussion for the next two slides. What is your takeaway from the results of using visual medication charts in clinical practice? When we first discussed this project our goal was to bridge the gap between the patient language of pill color and pill size with what we understand the pill name and the pill dose. And what he showed very elegantly was that it's possible to do this using a simple chart. Having said that one of the striking findings of this study to me was that over a very short period of time three to six months 45% of the patients had a change in the medication and 16% had a change in the doses. That to me is a huge takeaway and that also brings back that bridge that we have to form between patient language and physician language and the need to make it dynamic. Understanding that each encounter could be another time point where medications change, dosages change. How can we have a pill chart tool that's dynamic? And then we have one more. So what do you think the possible next steps are? Incorporating this in some way in the electronic medical record is important. They can show you a piece of paper that can be changed like an ABS and after visit summary after every encounter. So going to that would be important but one limitation I believe of our study is that there are so many manufacturers out there and the same pill can look different depending on the manufacturer and the manufacturer might change depending on insurance through the patient's lifespan in your clinic. So also addressing that part which we didn't really do in this current study is important to allow for widespread generalizability of this study. Okay so just to wrap everything up I think with more medications being introduced to guideline therapies their regimens for patients with cardiovascular disease are going to become more complex. So not only polypharmacy is already prevalent in our population there's also a high incidence of medication and doses changes. I think it is a value to obtain a baseline medication knowledge score in patients just to get a better understanding of what they know about their medications and possibly identify any specific barriers these patients might have to adhering to their medications. So overall I think something that's easily implementable and dynamic would be a really great tool for patients to have to address any issues from polypharmacy. These are my references. So it says how do you handle brand changes that affect the appearance of a patient drug. So I think I kind of addressed or that's something that's a limitation of our study is that if the patient's medications changes while we gave them this chart there's no way for us to quickly update that. So like we talked about for if something can get be in at least the pharmacy level or something that's integrated in the EMR where if they had brought their pills every visit then we can quickly update it or something that the patient can do as well. I think in terms of technology that would be a really great advance. Thank you. Okay our next speaker is Andrea Baer and she is coming from Arrhythmia Alliance. Her presentation is research and action building a sustainable model of reusing devices in low-income countries. Okay. As she said, my name is Andrea Baer, and I am from Arrhythmia Alliance, and we were running the program Peace for Life as we're discussing this project that we did, and it's building a sustainable model for reusing devices in low and middle-income countries. I have nothing to disclose. How do I? It's not moving. There we go. Nothing to disclose, except I don't know how to use the phone. So, in the United States, as we know, there's like 300,000 people who have CIEDs placed, and in the UK, about 78,000 each year. But there are significant disparities in low- and middle-income countries. There, about 2.5 million people die every year due to a lack of access from CIEDs. And the implantation rate in sub-Saharan Africa is 200 times less than the Western world, which means the death rate is one in two in countries that don't implant. So it's a serious issue. Meanwhile, here in the Western world, we have thousands of expired and explanted devices filling landfills in the developed nations from expired and end-of-shelf life devices that are just thrown away. So our solution is we think that by saving devices from landfills, we can provide life-saving cardiac care to individuals who otherwise would not have access to such treatment. And this program reduces barriers to care in those low- and middle-income countries while reusing supplies for maximum sustainability. And so it's a well-documented need that there are stark differences between the wealthy and developing nations in the use of CIEDs. And cardiovascular is the leading cause of death in these countries, and a significant burden of them are from rhythm-related disorders. But while permanent pacing has improved millions of lives, it's not coming along in the low- and middle-income countries like it is in the Western world. And with that increase of those cardiovascular implantable devices, philanthropic donations, it's just no way we can keep up. We have to find a different way to sustain the need. And then I just put in here that heart failure is associated with a substantial increase in mortality, morbidity, and poor quality of life, and it's a huge economic burden on national health care systems. And with higher poverty rates, low- and middle-income countries, while they're trying to curb poverty, it's led into this vicious cycle of if we can't figure out how to keep the population healthy, we're not going to be able to figure out how to get them out of poverty. And so as we are working on how to build a sustainable future, these are the methods that we are using. We're doing equipment donations with acquisition and management. We're doing pacing missions where we're training world-class leaders in these low- and middle-income countries while we equip their pacing units and teach, train, and support them in an ongoing basis. Because our goal really is that ultimately they're going to be able to do this on their own. We do a lot of partnering. We partner with My Heart, Your Heart through the University of Michigan who is working on a FDA-approved clinical trial process of reconditioning devices. We work with funeral homes and hospitals that give us their explanted devices, their expired end-of-shelf life devices. We have to work with the low- and middle-income countries, their hospitals, so that they can learn and get that information from us through that training. And we work with medical professionals and other charities because of information sharing, device procurement, supply deliveries. It really takes a village. And so we get a lot of our equipment donations and acquisition through funeral directors, pacing centers. We have program support. So we get a lot of word of mouth, a lot of websites, social media work, how we source devices. And so what happens when we get devices? So we have expired and end-of-shelf life devices. We have over five years battery life devices and under five years. Everything goes into one warehouse where it's kind of sorted. The end-of-shelf life and expired devices go straight into missions. So they're cataloged, and we send them straight off. The over five-year battery life are sent to the reconditioning, refurbishing, and re-sterilization. And then the under five-year battery life, they're not usable. We can't sustain. They're not worth really anything in our work, but we didn't want to leave them in landfills. So we send them to a recycling center that will save them from landfill. So we are at least trying to sustain that piece of it with the stuff that we can't do. One example of the supply deliveries is we did a large supply delivery to the Heart Institute in Kiev, Ukraine. They have the specialties. They have the scientists. They have the doctors. They just needed supplies because the war has been going on. So we were able to take all of the things that we had sourced that we could send them, pack it up, and ship it on to them. Excuse me. Reconditioned devices. I'm not going to go through this a lot because this is really not our expertise, but I just wanted to show that it was an FDA-approved process. It's in Phase III clinical trial right now at the University of Michigan through the My Heart, Your Heart, and they're doing a research-based process. And so we don't do that personally. Our work is really after that process has been done. And our missions can look a lot different depending upon where we are. The stars on the map is where we have touched in the last couple of years. Some of them are full missions. Some of them are training missions. We have done some supply deliveries. And then the ongoing training and support. We have a huge plethora of online training resources for HCPs and healthcare professionals that they can access at any time. And that training and teaching can be done on hands-on teaching at the site, educational days at the site, kind of like an HRS, but it's a one-day event. We have a virtual training center where they can go and learn any time that they want to. And then we also have one-on-one support, so we can connect them with peer mentors in either the U.S. or in the U.K. or in Europe, and they can call, ask questions, go through cases if they have any questions. And then, of course, we provide the admin and oversight for all of the missions, making sure that everything is done the way it needs to be done through government and oversight is managed so that these medical volunteers and all of our doctors can use their time and energy and effort to do what they do best, which is implanting devices and saving lives. So quickly, a case study in India. A lot of people ask why India. But despite India having a lot of progress being made, there is a huge inequity still in the socioeconomic status and geography and gender and depending upon where they live in the social construct. So it's really important for us to make sure that we don't look at one country and say, Oh, the country is rich, and so everybody is rich. And so we wanted to make sure that where we were going would be definitely needed. When we settled in on Bangalore in India, their population is over 14 million, and they have one charitable hospital in the entire region, and that is a hospital in Bangalore. They work 100% on donations and mission work. And so they are not—everybody gets free care who goes there, but the problem is they're very resource strapped. So we did two missions. We did one in March and one in October. We took expired or end-of-shelf life only. No reconditioned devices were allowed in India. But we were able to do—through the clinics, we were able to implant 134 devices, 120 device optimizations of people who had already had devices implanted, and we were able to screen 421 additional people for cardiac arrhythmias. 60% were male and 40% were female. And then we also performed the first ablation in that hospital. At the end of our October day mission, we had an HRU, which is a heart rhythm update, which is a one-day training of health care professionals, which was hugely successful. Over 200 people came and joined us. For the implantations and procedures, we had—it was almost equally distributed, with the pacemaker obviously being a little bit higher. But what I thought was interesting is the age. One, the breakdown of the age is clean across the lifespan, right? We had children through over 80 years old, but we also had a large percentage of them being 30-, 40-, and 50-year-olds, which means they're the breadwinners. They're the people who are keeping the families alive. They're people who need to be at their best health. Two short stories we had to highlight. On our first mission, we had a potato farmer. He was the only person who was able to support his family, and it was an extended family due to other deaths. He was taking care of over eight people, and he was the only person who had income. He was very sick, had a severe infection. He had to have the pacemaker that he had extracted, had to have the pocket flushed, antibiotics. But Dr. Mark Davies, who was with us on our team, took care of him and left with the instructions for the local team. On the second mission, he came back three days on a lorry. He came over just to say hello and to let everybody know that he was doing well. Then on the second mission, we had a girl who was 10. She came into the clinic that we were running and was experiencing unexplained syncope and ended up being diagnosed with Wolff-Parkinson's White and had an ICD placed, which saved her life, we're sure. Education and training goes daily education at the hospital each morning with pacing parameters and EP studies and maneuvers, hands-on experience during the procedures. Then, as I had said, we had our first heart rhythm update that was hosted with panel discussions, presentations, quizzes, hands-on training. To conclude, some of the key findings that we found over the past year when we were working in India and some other places is that every single country and region is unique, and we have to evaluate them for their needs. They don't all need the same thing, and so we can't bucket and say, this is everything we do for everybody. The clinical data for the use of the reconditioned devices for worldwide acceptance is vital, and I'm hopeful it's forthcoming because that will really free up a lot of devices for us to be able to use on missions. Upskilling and resource building for low and middle-income countries is central to their independence, and a long-term investment really is required to build the sustainabilities and centers. It doesn't really do us any good to go in on a feel-good mission for five or ten days and do some fuss stuff so we can show it on social media and say, look what we did. It's a long-term investment. It's a long-term... to be there long-term in that center for them to be sustainable. And so there's my information. If anybody is interested in learning more, I am happy to share information for you. Thank you. Thank you. Do you have a question? I'm looking. There he goes. So the question is, do you ever donate devices to animal missions clinics for their use? So we do not donate to animal clinics. We really focus on the human lifesaving. I do know there are people out there that do for animals, but we do not. And then the second question was, how likely are the patients to get another device once their generator reaches end of life, and are they prioritized? That's a great question. I think that every time we go into a country, before we go, we have a list of patients who have either been seen in clinic, or in the case of India, as we've seen them in clinic. And they are prioritized, unfortunately, in the way of lack of resources. We have to prioritize people who we know we can save their life with the pacemaker, and we know it's beneficial. We only have so many pacemakers, so many days. But we do the best we can. They would get another one. As I had said, our goal is to make sure that the countries that we're working in are self-sustaining. And so eventually, our goal is this Bangalore hospital in India can email me and say, hey, Andrea, I need 100 devices sent. Can you send them? And I could say, sure, because they don't need the training. They just need the devices. And so we're hoping that we get to that point with all of the hospitals eventually. Thank you very much. Thank you. Okay, our next speaker is Dr. Shalini Allam from the University of Pittsburgh. And her presentation today is left atrial appendage occlusion for bleeding AF patients as underrepresented findings of an EMR algorithm. Okay, thank you, everyone. Hi, everyone. My name's Shalini. I'm a cardiology fellow at University of Pittsburgh. I'm excited to discuss how we're gonna have, I'm gonna discuss how left atrial appendage occlusion in bleeding atrial fibrillation patients is underrepresented. For a little bit of background, the 2023 ACC AHA HRS guidelines for the management of atrial fibrillation emphasize how stroke risk and prevention remains one of the core pillars of AFib management. Unfortunately, anticoagulants are non-initiated and are maintained in over 50% of these eligible AFib patients, and this is due to a number of reasons, including clinically significant bleeds, drug interactions, cost of the medication, side effects, and noncompliance. But the emergence of left atrial appendage occlusion devices has opened a window of opportunity for these patients, and this therapy is unfortunately utilized at varying rates. In our study, we focused on utilizing an electronic medical record EMR algorithm to more efficiently identify patients who may qualify for left atrial appendage occlusion devices and to confirm the algorithm's accuracy. For the patients that we identified, we evaluated what their clinical care was for advanced therapies, including left atrial appendage occlusion. Our EMR algorithm identified 535 patient encounters at the University of Pittsburgh Medical Center from January to September 2020. The criteria we used were atrial fibrillation patients who were eligible for anticoagulation with a CHADS-VASc score of three or more and were admitted for a clinically significant bleed or acquired a blood transfusion during their admission. We then programmed our algorithm to exclude patients who had mechanical valves, left ventricular assist device, a history of left atrial appendage occlusion, were discharged to hospice during that hospitalization, or died during that hospitalization. We then manually reviewed the 535 encounters in order to confirm that our algorithm had been applied correctly. Once we had a final data set, we collected patient data through November 2024, which was approximately four years of follow-up. The information we collected on our patients included the CHADS-VASc score, confirmation that they had atrial fibrillation, anticoagulation that they were taking on admission and at discharge, the type of bleed that they were admitted for, whether cardiology evaluated the patient during or after their admission, and whether left atrial appendage occlusion was discussed during or after their admission. So, we started, can you just see this? Okay, so we started with 535 patient encounters. From these 535 encounters, we found that 411 encounters had patients who could be eligible for left atrial appendage occlusion, and 124 encounters did not. We then applied our algorithm to that same database and it was able to correctly identify 405 encounters and correctly removed 90 encounters. There were 34 encounters that were included that should have been removed, and six encounters that were excluded that should have been kept in the database. Overall, this resulted in a 92% positive predictive value, a 93% negative predictive value, a sensitivity of 98%, and a specificity of 72%. Our algorithm's overall accuracy was 92.5%. For the 34 encounters that should have been removed, 27 of them were patients who had a prior left atrial appendage occlusion or a mechanical valve, and we presumed that that may have been due to miscoding in the EMR that led them to being a part of the database. While the specificity of our algorithm was low, the goal was to have a very sensitive test in order to minimize exclusion of appropriate patients, and we felt that that was achieved in this case. During the 411 encounters, anticoagulants were reported in 313 encounters on admission, of which 65% of them were DOACs. There was 178 anticoagulants at discharge, of which 63% were DOACs, and the most common types of bleeds were gastrointestinal at 65%, followed by neurologic and genitourinary. Of the 411 encounters, they were made up of 385 unique patients. Our population of patients were 51% female, 77% of our population was over the age of 75, 95% of our patients had hypertension, and 38% of our patient had diabetes. The average CHADS VASc score was five, and finally, the left atrial appendage occlusion was discussed in 30% of the patients after admission. Only 7.5% of these patients then had left atrial appendage occlusion performed after four years of follow-up. There are a total of 88 patients who did not receive a left atrial appendage occlusion, despite having it being discussed after their hospitalization. 79% of these patients were seen by a cardiologist after the hospitalization, and the average time to follow up to specifically discuss left atrial appendage occlusion was 264 days. Finally, the most common reason these patients did not receive a left atrial appendage occlusion was due to the fact that they did not have a left atrial appendage occlusion or that they did not have a right atrial appendage occlusion or that they did not have a left atrial appendage occlusion was due to patient preference at 31%, or anticoagulation was restarted at 27%. In terms of our limitation, we did have 29 patients who had multiple encounters. Additionally, we feel that follow-up may have been affected for a number of patients due to the COVID-19 pandemic. In conclusion, our simple EMR algorithm was able to accurately identify patients who may be candidates for left atrial appendage occlusion. A limited number of our patients, 30% had left atrial appendage occlusion discussed, but only 7% of these patients actually had the implantation performed. This represents an opportunity to identify patients earlier who may be candidates for advanced atrial fibrillation therapies. In the future, we hope to further refine our algorithm by evaluating our algorithm prospectively. We will be considering clinical pathways to incorporate the results of this algorithm as well. Thank you again for your time, and I look forward to your questions. So the question is, that seems like a long time to consult and referral. Is that because of access issues, patient desire, or other reasons? Yeah, it's a great question. The way that we identified the number of days to follow up was going into each individual chart and searching for the terms left atrial appendage occlusion, LAO, LAC, and so on. And we were able to identify a number of patients who had left atrial appendage occlusion LAO, LAC, Watchman, Amulet, all the various names. And that was the date that that term was brought up first. And that's what we called it. And we had that be a patient encounter to say, that's how many days until then. So it was a long time for a lot of our patients. I don't know if that was necessarily only related to delays in getting them into the clinic. It was just the first time it was discussed, and it wasn't necessarily at a cardiology appointment. It may have been a primary care doctor, but maybe they didn't send a referral or a primary care doctor, and the patient moved to another state. It was really hard to delineate. Okay, thank you. Thank you very much. Our last presentation is Dr. Song-Young Shin from Korea University and Anson Hospital presenting on enhancing atrial fibrillation management. The impact of performance and quality measurements and implementation on clinical outcomes. Good afternoon, ladies and gentlemen. This is Seung Yong Shin, Korean University Hansan Hospital. It's my great pleasure to be here and present my topic. And today, my topic is Enhancing Atrial Fibrillation Management, the Impact of Performance Measure and Quality Measure on Clinical Outcomes. This study was supported by Korea NIH Fund. And AF associated strokes may lead to serious and irreversible outcomes and AF related strokes can be effectively prevented by oral anticoagulation. Therefore, stroke prevention in atrial fibrillation is a top priority recommendation by most guidelines. However, low implementation rate remains a challenge and highlighting the need for further research. Similar to low NOAC use in Korea and low NOAC use in the U.S. is a big issue in the U.S. as well. After introduction of NOAC in 2010, its use markedly improved OAC use but implementation rate is as low as 33% across the 10 years journey. This number needs to be improved. There is evidence supporting potential effect by increased implementation. Within this UK data, Professor Lipp showed dramatic reduction in outcome events by improved OAC use. The OAC use was as high as 84% and their mortality and stroke reduction was as high as 52% and 89% respectively. Previously, some tools to improve implementation, performance measure, and quality measurement was proposed. However, 24 items per patient is very hard to apply completely in daily practice. Our first question was by applying performance measurement and quality measurement tool, can clinical outcomes of AF patients be improved? First, we made Korean AF registry from 15 tertiary centers in South Korea. A total of 5.8 thousand AF patients were enrolled and performance measure and quality measure was assessed and they were followed up for two years. Within interim analysis, OAC use was as high as 85%. Therefore, we need a control group and the code AF registry, another Korean AF registry data was adopted as a control group. There is four years time gap between the two registries. This period is rapidly changing in terms of OAC use of NOAC introduction. And after propensity matching, matching variables are like this and we compare the two groups. Before propensity matching, the more AF at baseline and more pacemaker was identified in CS-BAP data. In terms of the stroke and bleeding, there is no significant differences between the two groups. But CHAD-VAC score was significantly different. Before propensity matching, more ACE inhibitor, ARB, and NOAC and anti-ardemic drug and beta-blockade use in CS-BAP group and more vitamin K antagonist and anti-platelet use in code AF group. After propensity matching, more AF in code AF group and more pacemaker in CS-BAP group. After PSM, similar stroke history and stroke risk in terms of CHAD-VAC score and more previous bleeding and malignancy in code AF data. And after propensity matching, more ACE inhibitor, ARB, NOAC, and beta-blockade anti-ardemic drug use in CS-BAP and more vitamin K antagonist and anti-platelet use in code AF is the same as before propensity matching. Next is the implementation rate of performance measure and quality measurement. All 24 items cannot be applied in terms of applicability and clinical validity. Therefore, we shorten it by 10 items, which is essential and valid items. One thing I have to address is the difference between number one and number two items. Somebody may ask, without CHAD-VAC score assessment and documentation, anticoagulation looks weird. But in patients with 75 or more and previous stroke history, further risk assessment is unnecessary for anticoagulation. And OH use was improved by 4.3% after performance measure and quality measure application. In terms of NOAC use, there was 19% improvement between the two groups. In terms of clinical outcomes, both stroke and bleeding were significantly reduced in CS-BAP group. Within regression analysis, appropriate NOAC dosing showed significant association with less bleeding events and more ACE inhibitor ARB use, marginally significant reduction in heart failure hospitalization. Performance measure and quality measure did improve OAC use and especially NOAC use. Improved OAC use showed further reduction of stroke and bleeding in comparison with contemporary clinical management. However, there is critical limitations between the two groups. The time gap, it cannot be fully reflected or compensated by crop past matching and more detailed analysis and comparison should be sought. Higher vitamin K antagonist and inteplated use may be associated with higher bleeding events in code AF. And appropriate heart failure management with ACE inhibitor or ARB and beta blockade use and avoid inappropriate dosing of NOAC may be associated with lower outcome events, stroke and bleeding in CS-BAP. And to be frank with you, it's really hard to apply and maintain our daily clinical practice. For its applicability and sustainability, some adjunctive tools are required. Ladies and gentlemen, let me conclude my talk. Performance measure and quality measure did improve clinical outcomes, both in efficacy and safety by facilitating OAC implementation. In addition to OAC use, general measures for AF care should be paid attention of clinicians. Thank you for your attention. Thank you very much. Any questions for any of our presenters that are here? Okay. Well, we will conclude this session. Thank you for joining us.

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